01070129 t` CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10441 CORTE DE MADRID TOM & CATHY LIFFLER 01070129
07 25 2001
PHONE: SANITARY NO. CONTROL NO,
G 0 z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
z U— BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
z 5 y- Job Description
O Z— 1 hereby uffrm that 1 am of he d unwired Bions of asCoda9(commencing REROOF.
rm:t-w with fall Section 70W)cf Division3 of the Business and Professions Code,and my license gx�� isceInnmiceandeBat. T/O WOOD SHAKE &
°',O m< License
tense Class Cant,.,.,
3 a ARCHITECT'S DECLARATION REPLACE W/30 YR. COMP.
c 1 nndersmnd my plans shut[be used as public records
�r
w i p Licensed Professional
°'x o OWNER-BUILDER DECLARATION
w—m I hereby affirm that 1 am exempt from the Contractor's Licenac Law for the
E Z 7 four,mg mm
mi_ISa,g.n]091.5,Bm
miucas and Pfeasinnc C°drrAny my u nm my
� to rlreqior to its Issuance,alsi to wnnruci.elms.inrpmu
ve,demolish,uupoir out'snunure
P
provisions
rtf ontowne
'hat he licensedFSe ion 7W p Division fm License S Ft F1oorArea $ uation
I ,-sglNsetefromanosoofineegtdexamarati.Anyvioloiol y 'it''"+ � ;,'.,.xxq'., kl,, l:';1 +ins'._.'>i' l':� : 30(�'�
r that io is exempt therefrom and the basis for the alleged exemption.Any violation -
-of Section003t. is any applicant for tpermit subjects the apPliromtoacivil penuhy
°/rbut mare than rye Honored dnlhr,esstw,. 3 7 5A��12m1�p I ' .� Occupancy Type
Rp 1,as owner of the propeny,or my employees with wages as their sate comcensmioo, ;
- w u no he weroram the aeratode:The is not intended en a aredLaw fertile(Sec:nus. 305 - FRAME Required Inspections l''' it
'Business grid Profession Code The C°ntmctreat License Law does not apply to an
a f p pent'Who builds or tops the a d who such rk himself
a'
through
h' n employees.provided that such improvements t am not intended or 307 - INSULATION -
'off"d f -1 If,however the bud 'ding rp t Id 'thin one y r of - -'
completion,the owneWr toes will lave the burden of proving that he did not build or
60T - ROOF TEAR OFF
w
impr..e for parpose°r sate.).
. ... 602 ROOF PLYWOOD. NAIL
Peamcewlu lyc contractingg int edmra vi 603 - _ROOF BATTENS .0ri -
.... -__.
con:�s«aweoject(Sec.7044naweteess and P fes,o Coda,)Th Contractor's 604 - ROOF IN-PROGRESS "
apply property who builds proves N n,
.. ._and whomntmar.forsuch projects with a contractorfs)lb d pursuant to.the. ..."....-_.._._... .. ... ... ...__-..._. ......__.... .. ..
A9me
Contractors License La
Oµ m�und 5 .' 'B&PCfonhis reason lt'�!- f.
FINALED
' r WOR R' �MPENSATION DECLARATION @ q q
Ihereby atB nderpiiltyrofperjury nt of the fll 'ng declarations, SEP 0 6 [0011
El h and will maintain "Cettlheate of Car,aar t It mean for Worker's
Compensation, as provided for by Section 37W of the Labor'Code,'for the
_ perfonnanceofNeworkforwhichthisPermitisissued.
ElI have and will maintain Workei s Compensation lot...noe,as required by Section BUILDING
3700 or the Labor Code,for the performmneee of the work for which this permit is
,.
is u d'MY Wo kers Coonnution Insurance carrier and Policynumber are;,
,RT ...
Ca :fFEXEM No: :, .. _,i.1. , w ,..n••.. t. i. . . ...: .Pyt r1 Il l I i
I CERTIFICATION IFICATION OF EXEMPTION FROM WORKERS';'
_'COMPENSATION INSURANCE ._ .... _-......-__... _...._.-_.._. .,_".,..._ _._........... .._....
(Ths sediEn need not be cnmplemd if the permit is for one hundred dollars " " PI '. •4
(ElWl nr lest.) -
,r 1 1,y that n the performance f th k f which this actualis
._ 1 .-.....- ._.. .
shallnet employ saved,
p,y y person n any manner so m beco re suh'so to the Workers
C p ation Laws all
Du �'
Appl ant.' .
,NOTICE TO
Q APPLICANTpto,yo -h
0subjectoth Worker,C iper t ep '.icav of the LaborCde,y us,
forthwith ply with such provisions or this permit shall be deemed
revoker,
CONSTRUCTIONLENDING AGENCY - r ',I:' J.
of' f heieby affirm that th a conanurflon lending ag<n y for the pedommiabw
Lcr de -
....L 'NNapm --
ame'- :..... -... .. .. _...-
�rZ )s d Add r r i .-
U_Q 1 ceunfy that I have read Nis implication and stare shot the above information's
ti,F or
erecu iI agree to comply with all city and county°rdimartme and state laws relating
r.Q*U to building construction,and hereby authorize repra,anutives of this city to enter upon
rW the above.mentioned property for inspection purposes.
- �;L eWJ prcet a d ni�a dkeph
U W liabilitiesjited,oural,cast,.,,it
which mayinany a,
i+rCpc'nngnat'
.lsaid
City in consequence granting ofth permit.i� APPLICANT UNDERSTAND
WILL COMPLY WITH ALL 1,16001NT
sou R cuLAn 7-Z-trod Issued by: Date
S'gnatufe of Applica t/Ciatb t 'Date - Re-roofs
HAZARDOUSMATERIALS DISCLOSURE'
Will rb6 applicant or from,budding occuport.store or,handle buiscificaus=most. . ,,,�I e of Roof-
' udf dbyth Cupertino M impalCd Chapter9,12 d theHealth andSafety
'JP d l tr p_ a � •,. '�- "' ""' --' "'"'"'" "
7.
cast zssJ c I All roofs shall be inspected first tib
Ilya, p ' any.roofing.mater al.being installed . _. ._.._..,._
Will the o r t buildingoccupantuseequipmento u e which f a roof is mstalled'wi obtaining an ins ection}I'a�ree tolremove
e t h d air contaminants Bay Area A Quality Management g P b
D
Distort.' :. all new materials for.inspection.,A licant understands and comply
❑Y sva r a nY Int, ,t. .._ P PP .. ,-.
is a
all non-point source regulations'.,
1 havc�...d the.facoirdores'nosensh,mquiramactluadcr Chapter 6.95 of the
i
Calibration tCode. ctina�5505255JJand255
[ d omilnat
'-f the building d enot ady htenant.that it is y responsibility to notify the
o of the
ntsluet t missuancef a Certificate of
— Opg � Signature ofAKcantDate
o n authorizedagent
'i "'--- -- -
a e t Date, All roof coverings to be Class `B"or better
t
_ .OFFICE --.-. _._... _ .. -.. -. ._ . ..._